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LUl:A11UP1 1r1L 1uu3Y!4 ...�,■, rLGM�IG AC111111 1%l: 4554 S.El Dorado St. Nevada 019 _ __ =M=, __ __ P.O. Box 83328 Stockton, CA 95206 Wa WM100035 '? s_ $_ Portland,OR 97283 Stockton &Sacramento Area(209) 234-0700 WASTE RECOVERY WEST.INC. 1-877-OLD-TYRE Redding Area(530)2754160 //'� Hauler ❑End Use Facility ,f P, /� ❑Generator I �/� � � ErPickup Invoice Date d ' k? L ad Date ,f ,&tot _.. Phone 3� 1 ❑Delivery Customer Name L._y " ' c1 � rrl ` " Acct# Site Street Address ' `- I�r A V,: !� !) ,y C�4 City State Zip �.%-_�•_ , DRIVER F I certify that unlder penalty of perjury under the laws of the State of California that the information provided is true and correct.In addition,l am � •' aware that"cation of this information may result in suspension,revocation,or denial of renewal of the Waste Tire Hauler Registration pursuant to —'1`f-'''1 r `• Public Resourcfs Code section 42960 and may result in civil penalties up to$25,000 per day,per violation or administrative penalties up to$5,000 per x___ _' _�___ _ violation per dt as described in Public Resources Code action 42962. Hauler Exemption ❑Govemment (]LEA - � Agriculture (]Common Carrier TRUCK# HAULER- TRLRLGTH TRLR WS y` DRIyER/HELPER+` MANIFEST# CASH/CHARGE LIC.PLATE# DECAL# LIC.STATE I IMPORT ❑ LOCATION CUSTOM,ERTPID#:_ TRIP LOG •i?��f yt� - - EXPORT ❑ f LOAD AMOUNT Description LOAD TYPE Rate Amount UAN-ITY _ _ C-T-Y-P Passenger Tires Q Passenger Tires on rim Q 1 Manifest Fee 1.50 1.50 f f Customer Signature j` _ I Total Amount$ "4I artily that under pcn of penury:under the laws of the Site of California that the information prodded above is true and cor- rect.In addition,I am(ware at falsification of this'nforma'bbra may result in civ l penalties up to 25,i:0J per day,per violation or /� ``[�q� administrative penalties up to$5,000 per violation per day as lesetibed in Public Resources Code section 4962. I I49�I/O�O G O 1188 8 Y)2 6